The "Childmyths" blog is a spin-off of Jean Mercer's book "Thinking Critically About Child Development: Examining Myths & Misunderstandings"(Sage, 2015; third edition). The blog focuses on parsing mistaken beliefs that can influence people's decisions about childrearing-- for example, beliefs about day care, about punishment, about child psychotherapies, and about adoption.
See also http://thestudyofnonsense.blogspot.com

Concerned About Unconventional Mental Health Interventions?

Wednesday, June 3, 2015

Some weeks ago, when I had written a post about the
Oregon psychologist Kali Miller and the revocation of her license (http://childmyths.blogspot.com/2015/03/psychology-license-revoked-become.html),
one Robert Plamondon commented with severe criticism of psychology licensing
boards and advice that unhappy clients of psychologists should sue the
practitioners directly instead of going through the licensing board. I pointed
out in response that when children were the patients, they did not have the
capacity to sue for personal injury, and if their parents had made the decision
to seek the treatment, or even carried out some of the treatment themselves,
the parents would probably not bring suit on the children’s behalf (behalves?).

I see now that Plamondon has a web site, www.unlicensed-practitioner.com,
which purports to provide resources to help alternative and unlicensed
practitioners operate “legally and ethically” in Oregon. As far as I can tell,
Plamondon objects to decisions made by the Oregon board of psychologist
examiners, but in addition he favors mental health treatment by unlicensed
persons in a general sort of way. This may be in part because he himself is practicing
as a hypnotherapist.

I would be the first to admit that national professional
organizations like the American Psychological Association and the National
Association of Social Workers have strong “guild” mentalities and are much concerned
about their professional hegemony. The current scandal about the involvement of
APA with approval of torture is evidence that focusing on putting the
profession forward can interfere with everyday ethical decisions, not to speak
of professional ethics. But to my mind these are not reasons to abandon
regulation through licensure and other methods.

Why do I think this? What are the advantages to the
public of licensing mental health professionals? Why, especially, do the
educational requirements for licensure benefit the public? There are two
primary reasons for requiring practitioners to meet licensing standards and to do so through formal education-- and neither of them has much to do with
whether the practitioner has learned specific techniques of therapy.

The first concern has to do with education about the
nature of evidence and the ways we can test the effectiveness of treatments.
Plamondon himself states that the major difference between psychologists and
counselors is that psychologists are trained to do scientific research. From the
point of view of patients, there is probably no advantage to visiting a practitioner
who is doing actual research (i.e.,
collecting data systematically), but there is an enormous advantage to going to
someone who can read research, which
few people are able to do well unless they have studied research methods. Practicing
psychologists, social workers, and other mental health professionals should be
capable of understanding when research evidence supports the use of a treatment
method, when there is no such support, and when a treatment is potentially
harmful to patients. No licensure can insure
that practitioners do their homework, but licensing standards can require that professionals have gone through
the formal educational process that should provide them with the skills to
understand research evidence.

Unlicensed practitioners may be competent and
careful about the evidence basis of the treatments they use, but it appears likely
that most of them are not. This point is made by Plamondon’s tendency to refer
to “unlicensed and alternative” practitioners. Alternative practitioners by
definition use methods that lack evidence of effectiveness; if this were not
the case, there would be nothing “alternative” about them. Plamondon himself
displays his lack of concern with evidence of treatment effectiveness by his
references to such methods as Neurolinguistic Programming (NLP) and
sensorimotor psychotherapy. These therapies, which Plamondon apparently finds admirable,
are without acceptable research support. It is not illegal to use them, but it
would be difficult to argue that such use is demonstrably in the best interest
of the public. In some cases, methods used by alternative practitioners are not
only ineffective, but potentially harmful—as in the case of “conversion”
therapy and the related “holding” therapy.

These facts lead us to a second issue about
education required by licensing standards. Licensed mental health practitioners
have to show that they have been through educational programs that included
study of professional ethics. Unlicensed practitioners may be perfectly ethical
people in their daily lives, but may be without training in some of the special
issues of professional ethics. For example, in daily life, it is “not nice” but
not strictly unethical to tell a juicy piece of gossip that has been disclosed
to us; in mental health practice, confidentiality is an ethical obligation that may be handled well only if someone has
been trained to think clearly about conflicting motives and benefits. (Does the
psychologist tell a patient’s family member that the patient seems to be
considering suicide? ) Similarly, in daily life, it does no harm for someone to
socialize with a person he employs or works for; in mental health work, the
wearing of “two hats” in dual relationships creates a variety of ethical
problems, which may be avoided only when earlier training and practice have
alerted a practitioner. No one would claim that all licensed mental health
professionals are always able to make the right choices in professional ethics
(as any state’s list of disciplinary decisions shows), but a requirement of appropriate
education excludes from practice persons who have never received formal
instruction about ethical choices.

In his earlier comment, Plamondon suggested that
patients who have been injured should bring personal suits against mental
health practitioners rather than bringing a complaint to a licensing board. Let
me point out that personal injury suits are time-limited and in some states
cannot be brought more than a year after the event that caused the claimed
injury. Although it can happen that the time limit clock starts when the person
realizes that an injury was done, in that case the defense for a practitioner may be a motion to dismiss the
case because the individual “should have known” earlier that there had been an
injury caused by a treatment. A number of suits by adults who were harmed by
inappropriate mental health practices when they were children have failed
because the individuals did not manage to understand that they had been harmed
and to find counsel for several years after the 18th birthday. Thus
personal injury suits are often ineffective ways to obtain redress for people
who have been harmed by alternative mental health practices. Similarly, suits
for fraudulent deception are likely to fail either on the ground that an injury
or loss cannot be clearly demonstrated, or on the ground that the practitioner believed
the treatment would be effective and not harmful. Protection of commercial
speech in the United States makes fraud even more difficult to prove.

Because of the difficulties of finding justice for people
who have been harmed by alternative or unlicensed mental health practitioners,
I would argue that in spite of many and various holes in the system, the best
choice for the patient is a licensed mental health practitioner, and the best
governmental choice is to continue and
strengthen licensing requirements.

Tuesday, June 2, 2015

Recently, someone commenting on a post on this blog
asked me to explain why I had said that diagnosis of mental illness in research
did not have to be, or at least was not, as accurate as was needed in treatment
of an individual. The writer pointed out that therapists may make a diagnosis not
so much because it is accurate but because it allows particular treatments or
services to begin. This is certainly true, and it’s also true that psychosocial
treatments are often directed at specific symptoms that are troubling rather
than at some underlying condition that has been diagnosed. That’s a good idea
in many cases, especially when the proposed condition, like Reactive Attachment
Disorder, does not necessarily have the causes that are posited for it.

My remarks were not about how things actually are,
or about the best they can be in light of various social and political pressures.
Instead, I was thinking about the kinds of questions researchers and therapists
are asking, and the ways these questions differ from each other. Researchers
are almost invariably asking whether one group
of people is different from another, or about what will happen to a group
given one treatment, as compared with a group given another treatment. They
expect some variability within groups and would be surprised and even suspicious
if everyone in a group acted the same way. They also accept the fact that
diagnostic measures vary in their accuracy.

Therapists, on the other hand, want to know what
will be the effect on a particular person of a treatment or experience. They
have much less wiggle room than researchers do, especially in cases where a
patient may or may not behave violently. We are all aghast every time we read
that a formerly violent patient was allowed a weekend pass from a hospital,
went home, and chopped up his mother with an ax. “Why didn’t they know that
would happen?," we demand.

A useful article in Science (“What is the question?, by Jeffrey Leek and Roger Peng, 20
March 2015, pp. 1314-1315) provides some ways of thinking about these issues.
Leek and Peng even give a great flowchart, and I am going to shamelessly follow
their description of making decisions about the kinds of questions that are being
asked by researchers, therapists, and lots of other people.

The first question Leek and Peng ask about how
people think about information they have available is, “did you summarize the
data?” If this hasn’t been done-- for
example, if there are only anecdotes or testimonials in use—there is no data
analysis, and no prediction can be done. (For example, about whether a particular
treatment produced a better outcome than another did. )

If the information was summarized, but reported without
any interpretation, this was a descriptive
approach, but again no prediction can be done.

What if the information was not only summarized, but
interpreted—but there was no attempt to decide whether the patterns seen would
be repeated in other circumstances? Work of this kind is exploratory. Whatever patterns or connections exist between factors
(like treatments experienced), they still need to be confirmed by more work.

Did the study quantify the differences observed and
calculate the probability that they would be repeated? If so, there are further
questions to be asked. The first one is whether someone is trying to figure out
how the average of one measurement affects another measurement. If this is not
being done, the next question is whether the goal is to predict measurements
for individuals. No? Then the study is an inferential
one, which just looks for relationships between factors. Yes? The study is
a predictive one. It attempts to
predict what will happen with a single individual-- but without being able to understand how or
why effects occur, and therefore without real certainty.

Suppose there is an effort to find out how changing
the average of one measurement changes another? This may be a study that is causal in nature. It can demonstrate
that a group of people receiving a treatment do better on average than a group
receiving a different treatment, but is not able to predict which people will
do well or poorly—only the average change in risk or benefit is calculated.
Leek and Peng give the example of smoking as a risk factor for lung cancer. As
we all know, some people who smoke will be very badly affected, and others
affected very little, but the whole group of smokers will be more likely to
have lung cancer than the whole group of non-smokers (some of whom will get
lung cancer too). To take a psychological example, we have the evidence that of
depressed people taking antidepressants, many will do better than a matched
group without the medication, but some in both groups may kill themselves.

The highest level of explanation involves a deterministic or mechanistic analysis. In this case, the evidence shows that
changing one measurement is reliably and exclusively followed by a specific
change in another measurement. As Leek and Peng put it, “Outside of
engineering, mechanistic data analysis is extremely challenging and rarely
achievable.”

When researchers are working on psychological changes
in groups as a result of treatments or experiences, they may be working at
anywhere from an inferential to a causal level, but their concern is still
about average changes in groups. If therapists are trying to be predictive, they may not be able to do a
good job of prediction if (as is common) they really do not understand how or
why certain results are brought about. Without understanding what events lead
to the patient chopping up Ma with the ax, predicting that event is hard; it
may be right most of the time, and most weekend passes do not lead to mayhem,
but the predictive failure makes it clear that the cause of the behavior is not
well understood. However, the more accurate the information is—for example, the
better the diagnosis—the better the chances that the individual prediction will be
correct.

But human behavior rarely involves a single event
that is always and exclusively followed by another specific event. Instead, a
broad range of events work together to bring about most outcomes, even those
that seem quite isolated, like an ax murder. In aeronautical engineering,
factors like wing design can directly affect air flow, but human behavior
probably has few factors that are the sole cause of an event. Predicting
individual human behavior is much more like meteorology, in which a broad range
of factors can determine thunderstorms (does that cold front keep moving or
not?) or ax murders (does Ma take the opportunity to tell the patient who his
real father is?). Not all of these are
known—or even can be known—at the time of the prediction.

About Me https://en.wikipedia.org/wiki/Jean_Mercer

Jean Mercer has a Ph.D in Psychology from Brandeis University, earned when that institution was 20 years old (you do the math). She is Professor Emerita of Psychology at Richard Stockton College, where for many years she taught developmental psychology, research methods, perception, and history of psychology. Since about 2000 her focus has been on potentially dangerous child psychotherapies, and she has published several related books and a number of articles in professional journals.
Her CV can be seen at http://childmyths.blogspot.com/2009/12/curriculum-vitae-jean.mercer-richard.html.